[An invisible splinter in the finger]. / Een onzichtbare splinter in de vinger.

A 45 year old male reported to the ER after having removed a splinter from his right index finger. He felt a piece of wood still remained. Using the POCUS waterbath-technique we were able to easily locate the splinter, and eventually remove it under local anesthesia.

New clinical prediction model for early recognition of sepsis in adult primary care patients: a prospective diagnostic cohort study of development and external validation.

BACKGROUND: Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs. AIM: To develop and validate a sepsis prediction model for adult patients in primary care. DESIGN AND SETTING: This was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020. METHOD: Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations. RESULTS: A total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation. CONCLUSION: Based on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.

BET 1: Functional treatment is non-inferior to below the knee cast in adults with acute closed proximal fifth metatarsal fractures.

A short cut review was carried out to establish whether functional treatment is better than conservative treatment with a below knee cast at decreasing time to functional recovery and fracture union in adults with an acute closed proximal fifth metatarsal fracture. Four papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that in proximal (zone 1 and 2) fractures of the fifth metatarsal functional treatment with immediate mobilisation is at least non-inferior to immobilisation in a cast.

The association between systolic blood pressure and in-hospital mortality in older emergency department patients who are hospitalised with a suspected infection.

OBJECTIVE: In existing risk stratification and resuscitation guidelines for sepsis, a hypotension threshold of systolic blood pressure (SBP) below 90-100 mmHg is typically used. However, for older patients, the clinical relevance of a SBP in a seemingly 'normal' range (>100 mmHg) is still poorly understood, as they may need higher SBP for adequate tissue perfusion due to arterial stiffening. We therefore investigated the association between SBP and mortality in older emergency department (ED) patients hospitalised with a suspected infection. METHODS: In this observational multicentre study in the Netherlands, we interrogated an existing prospective database of consecutive ED patients hospitalised with a suspected infection between 2011 and 2016. We investigated the association between SBP categories (≤100, 101-120, 121-139, ≥140 mmHg) and in-hospital mortality in patients of 70 years and older. We adjusted for demographics, comorbidity, disease severity and admission to ward/intensive care using multivariable logistic regression. RESULTS: In the 833 included older patients, unadjusted in-hospital mortality increased from 4.7% (n=359) in SBP ≥140 mmHg to 20.8% (n=96) in SBP ≤100 mmHg. SBP categories were linearly associated with case-mix-adjusted in-hospital mortality. The adjusted ORs (95% CI) for ≤100, 101-120 and 121-139 mmHgcompared with the reference of ≥140 mmHg were 3.8 (1.8 to 7.8), 2.8 (1.4 to 5.5) and 1.9 (0.9 to 3.7), respectively. CONCLUSION: In older ED patients hospitalised with a suspected infection, we found an inverse linear association between SBP and case-mix-adjusted in-hospital mortality. Our data suggest that the commonly used threshold for hypotension is not clinically meaningful for risk stratification of older ED patients with a suspected infection.

Development and validation of an admission prediction tool for emergency departments in the Netherlands.

OBJECTIVE: Early prediction of admission has the potential to reduce length of stay in the ED. The aim of this study is to create a computerised tool to predict admission probability. METHODS: The prediction rule was derived from data on all patients who visited the ED of the Rijnstate Hospital over two random weeks. Performing a multivariate logistic regression analysis factors associated with hospitalisation were explored. Using these data, a model was developed to predict admission probability. Prospective validation was performed at Rijnstate Hospital and in two regional hospitals with different baseline admission rates. The model was converted into a computerised tool that reported the admission probability for any patient at the time of triage. RESULTS: Data from 1261 visits were included in the derivation of the rule. Four contributing factors for admission that could be determined at triage were identified: age, triage category, arrival mode and main symptom. Prospective validation showed that this model reliably predicts hospital admission in two community hospitals (area under the curve (AUC) 0.87, 95% CI 0.85 to 0.89) and in an academic hospital (AUC 0.76, 95% CI 0.72 to 0.80). In the community hospitals, using a cut-off of 80% for admission probability resulted in the highest number of true positives (actual admissions) with the greatest specificity (positive predictive value (PPV): 89.6, 95% CI 84.5 to 93.6; negative predictive value (NPV): 70.3, 95% CI 67.6 to 72.9). For the academic hospital, with a higher admission rate, a 90% probability was a better cut-off (PPV: 83.0, 95% CI 73.8 to 90.0; NPV: 59.3, 95% CI 54.2 to 64.2). CONCLUSION: Admission probability for ED patients can be calculated using a prediction tool. Further research must show whether using this tool can improve patient flow in the ED.

Introducing copayments in the emergency department would deter appropriate visits in the Netherlands.

OBJECTIVE: To determine what the effects of introduction of copayments for self-referred emergency department (ED) visits would be in the Netherlands and at what amount patients would turn to a GP before visiting an ED. METHODS: This questionnaire study was carried out in the ED of the Rijnstate Hospital, a community teaching hospital in the Netherlands. In the Netherlands, a deductible excess system is in use and this study investigated the effects of a copayment for self-referred patients (SRPs) on top of the deductible excess. A questionnaire was developed and handed out to SRPs. RESULTS: A total of 433 SRPs were included; their average age was 33.1 years and 63% were male. With a copayment of &OV0556;100, 47% of SRPs would choose to visit their GP instead of the ED. A further increase in the copayment amount is largely ineffective in reducing the number of self-referred ED visits. The higher the household income and education level and the more urgent the triage category, the larger the copayment patients are willing to pay. There is no significant relation between appropriateness and the amount of copayment that patients are willing to pay and we found no specific copayment level that resulted in reducing mainly inappropriate ED visits. CONCLUSION: With a copayment of &OV0556;100, 47% of the SRPs would choose to visit their GP instead of the ED. There was no specific copayment level that resulted in reducing mainly inappropriate ED visits.

Initial disease severity and quality of care of emergency department sepsis patients who are older or younger than 70 years of age.

OBJECTIVE: Due to atypical symptom presentation older patients are more prone to delayed sepsis recognition. We investigated whether initial disease severity before emergency department (ED) treatment (including treatable acute organ dysfunction), quality of ED sepsis care and the impact on mortality was different between patients older and younger than 70 years. If differences exist, improvements are needed for ED management of older patients at risk for sepsis. METHODS: In this observational multicenter study, ED patients who were hospitalized with a suspected infection were stratified by age <70 and ≥70 years. The presence of treatable and potentially reversible acute organ dysfunction was measured by the RO components of the Predisposition, Infection, Response and Organ dysfunction (PIRO) score, reflecting acute sepsis-related organ dysfunction developed before ED presentation. Quality of care, as assessed by the full compliance with nine quality performance measures and the standardized mortality ratio (SMR: observed/expected in-hospital mortality), was compared between older and younger patients. RESULTS: The RO-components of the PIRO score were 8 (interquartile range; 4-9) in the 833 older patients, twice as high as the 4 (2-8; P<0.001) in the 1537 younger patients. However, full compliance with all nine quality performance measures was achieved in 34.2 (31.0-37.4)% of the older patients, not higher than the 33.0 (30.7-35.4)% in younger patients (P = 0.640). In-hospital mortality was 9.2% (95%-CI, 7.3-11.2) in patients ≥70, twice as high as the 4.6% (3.6-5.6) in patients <70 years, resulting in an SMR (in study period) of ~0.7 in both groups (P>0.05). CONCLUSION: Older sepsis patients are sicker at ED presentation but are not treated more expediently or reliably despite their extra acuity The presence of twice as much treatable acute organ dysfunction before ED treatment suggests that acute organ dysfunction is recognized relatively late by general practitioners or patients in the out of hospital setting.

The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study.

BACKGROUND: Sepsis recognition in older emergency department (ED) patients is difficult due to atypical symptom presentation. We therefore investigated whether the prognostic and discriminative performance of the five most commonly used disease severity scores were appropriate for risk stratification of older ED sepsis patients (≥70 years) compared to a younger control group (<70 years). METHODS: This was an observational multi-centre study using an existing database in which ED patients who were hospitalized with a suspected infection were prospectively included. Patients were stratified by age < 70 and ≥70 years. We assessed the association with in-hospital mortality (primary outcome) and the area under the curve (AUC) with receiver operator characteristics of the Predisposition, Infection, Response, Organ dysfunction (PIRO), quick Sequential Organ Failure Assessment (qSOFA), Mortality in ED Sepsis (MEDS), and the Modified and National Early Warning (MEWS and NEWS) scores. RESULTS: In-hospital mortality was 9.5% ((95%-CI); 7.4-11.5) in the 783 included older patients, and 4.6% (3.6-5.7) in the 1497 included younger patients. In contrast to younger patients, disease severity scores in older patients associated poorly with mortality. The AUCs of all disease severity scores were poor and ranged from 0.56 to 0.64 in older patients, significantly lower than the good AUC range from 0.72 to 0.86 in younger patients. The MEDS had the best AUC (0.64 (0.57-0.71)) in older patients. In older and younger patients, the newly proposed qSOFA score (Sepsis 3.0) had a lower AUC than the PIRO score (sepsis 2.0). CONCLUSION: The prognostic and discriminative performance of the five most commonly used disease severity scores was poor and less useful for risk stratification of older ED sepsis patients.

Inclusion of emergency department patients in early stages of sepsis in a quality improvement programme has the potential to improve survival: a prospective dual-centre study.

STUDY OBJECTIVE: Sepsis quality improvement programmes typically focus on severe sepsis (ie, with acute organ failure). However, quality of ED care might be improved if these programmes included patients whose progression to severe sepsis could still be prevented (ie, infection without acute organ failure). We compared the impact on mortality of implementing a quality improvement programme among ED patients with a suspected infection with or without acute organ failure. METHODS: This prospective observational study among ED patients hospitalised with suspected infection was conducted in two hospitals in the Netherlands. After stratification by sepsis category (with or without organ failure), in-hospital mortality was compared between a full compliance (all quality performance measures achieved) and an incomplete compliance group. Multivariable logistic regression analysis was used to quantify the impact of full compliance on in-hospital mortality, adjusting for disease severity, disposition and hospital. RESULTS: There were 1732 ED patients and 130 deaths. Full compliance was independently associated with approximately two-thirds reduction in the odds of hospital mortality (adjusted OR of 0.30 (95% CI 0.19 to 0.47), which was similar in patients with and without organ failure. Among the 1379 patients with suspected infection without acute organ failure, there were 64 deaths, 15 (1.1%) in the full compliance group and 49 (3.6%) in the incomplete compliance group (mortality difference 2.5% (95% CI 1.6% to 3.3%)). Among 353 patients with organ failure, there were 66 deaths, 12 (3.4%) in the full compliance compared with 54 (15.3%) in the incomplete compliance group (mortality difference 11.9% (95% CI 8.5% to 15.3%)). Thus, there was a difference of 76 deaths between full and incomplete compliance groups, and 34 (45%) who benefited were those without acute organ failure. CONCLUSIONS: Sepsis quality improvement programmes should incorporate ED patients in earlier stages of sepsis given the potential to reduce in-hospital mortality among this population.

Why patients self-refer to the Emergency Department: A qualitative interview study.

RATIONALE, AIMS, AND OBJECTIVES: There have been multiple studies investigating reasons for patients to self-refer to the Emergency Department (ED). The majority made use of questionnaires and excluded patients with urgent conditions. The goal of this qualitative study is to explore what motives patients have to self-refer to an ED, also including patients in urgent triage categories. METHODS: In a large teaching hospital in the Netherlands, a qualitative interview study focusing on reasons for self-referring to the ED was performed. Self-referred patients were included until no new reasons for attending the ED were found. Exclusion criteria were as follows: not mentally able to be interviewed or not speaking Dutch. Patients who were in need of urgent care were treated first, before being asked to participate. Interviews followed a predefined topic guide. Practicing cyclic analysis, the interview topic guide was modified during the inclusion period. Interviews were recorded on an audio recorder, transcribed verbatim, and anonymized. Two investigators independently coded the information and combined the codes into meaningful clusters. Subsequently, these were categorized into themes to build a framework of reasons for self-referral to the ED. Characteristic quotes were used to illustrate the acquired theoretical framework. RESULTS: Thirty self-referred patients were interviewed. Most of the participants were male (63%), with a mean age of 46 years. Two main themes emerged from the interviews that are pertinent to the patients' decisions to attend the ED: (1) health concerns and (2) practical issues. CONCLUSIONS: This study found that there are 2 clearly distinctive reasons for self-referral to the ED: health concerns or practical motives. Self-referral because of practical motives is probably most suitable for strategies that aim to reduce inappropriate ED visits.

Motives for self-referral to the emergency department: a systematic review of the literature.

BACKGROUND: In several western countries patients' use of Emergency Departments (EDs) is increasing. A substantial number of patients is self-referred, but does not need emergency care. In order to have more influence on unnecessary self-referral, it is essential to know why patients visit the ED without referral. The goal of this systematic review therefore is to explore what motivates self-referred patients in those countries to visit the ED. METHODS: Recommendations from the PRISMA were used to search and analyze the literature. The following databases; PUBMED, MEDLINE, EMBASE, CINAHL and Cochrane Library, were systematically searched from inception up to the first of February 2015. The reference lists of the included articles were screened for additional relevant articles. All studies that reported on the motives of self-referred patients to visit an ED were selected. The reasons for self-referral were categorized into seven main themes: health concerns, expected investigations; convenience of the ED; lesser accessibility of primary care; no confidence in general practitioner/primary care; advice from others and financial considerations. A random-effects meta-analysis was performed. RESULTS: Thirty publications were identified from the literature studied. The most reported themes for self-referral were 'health concerns' and 'expected investigations': 36% (95% Confidence Interval 23-50%) and 35% (95% CI 20-51%) respectively. Financial considerations most often played a role in the United States with a reported percentage of 33% versus 4% in other countries (p < 0.001). CONCLUSIONS: Worldwide, the most important reasons to self-refer to an ED are health concerns and expected investigations. Financial considerations mainly play a role in the United States.

Independent predictors of major adverse cardiovascular events in emergency department patients who are hospitalised with a suspected infection: a retrospective cohort study.

OBJECTIVE: Emergency department (ED) patients hospitalised with a suspected infection have an increased risk for major adverse cardiovascular events (MACE). This study aims to identify independent predictors of MACE after hospital admission which could be used for identification of high-risk patients who may benefit from preventive strategies. SETTING: Dutch tertiary care centre and urban hospital. PARTICIPANTS: Consecutive, hospitalised, ED patients with a suspected infection. DESIGN: This was a secondary analysis using an existing database in which consecutive, hospitalised, ED patients with a suspected infection were prospectively enrolled. Potential independent predictors, including illness severity, as assessed by the Predisposition, Infection, Response, Organ failure (PIRO) score, and classic cardiac risk factors were analysed by multivariable binary logistic regression. Prognostic and discriminative performance of the model was quantified by the Hosmer-Lemeshow test and receiver operator characteristics with area under the curve (AUC) analyses, respectively. Maximum sensitivity and specificity for identification of MACE were calculated. PRIMARY OUTCOME: MACE within 90 days after hospital admission. RESULTS: 36 (2.1%) of the 1728 included patients developed MACE <90 days after ED presentation. Independent predictors of MACE were the RO components of the PIRO score, reflecting acute organ failure, with a corrected OR (OR (95% CI) 1.1 (1.0 to 1.3) per point increase), presence of atrial fibrillation/flutter; OR 3.9 (2.0 to 7.7) and >2 classic cardiovascular risk factors; 2.2 (1.1 to 4.3). The AUC was 0.773, and the goodness-of-fit test had a p value of 0.714. These predictors identified MACE with 75% sensitivity and 70% specificity. CONCLUSIONS: Besides the classical cardiovascular risk factors, atrial fibrillation and signs of acute organ failure were independent risk factors of MACE in ED patients hospitalised with a suspected infection. Future studies should investigate whether preventive measures like antiplatelet therapy should be initialised in hospitalised ED patients with suspected infection and high risk for MACE.

Self-referrals in a Dutch Emergency Department: how appropriate are they?

OBJECTIVE: Self-referred visits account for an average of 30% of all Emergency Department (ED) visits in the Netherlands. Some of these are considered inappropriate, because patients receive care that a GP can provide. Worldwide, studies have used various methods to determine the proportion of inappropriate visits by self-referred patients, resulting in diverging percentages. The aim of this study was to find a reliable percentage of appropriate visits to the ED by self-referred patients in the Netherlands. METHODS: This observational, prospective study was performed in the ED of a hospital in the Netherlands. Data were collected on all self-referred patients in four separate months over 1 year. The appropriateness of an ED visit was determined at two time points: first, after primary assessment of the patient, using predefined criteria, and second the moment the patient left the ED, on the basis of the diagnosis and treatment received. Finally, the perspective of the patients was taken into account using a questionnaire. RESULTS: In 4 months 3196 self-referred patients were included. In all, 1862 (58.8%) visits were classified as appropriate according to the predefined criteria. When the second time point was taken into consideration, 48.1% of the patients had a secondary care diagnosis and/or needed secondary care treatment, classifying their visits as appropriate. According to the opinion of the patients 76.7% classified their visit as appropriate. CONCLUSION: The percentage of appropriate ED visits by self-referred patients in the Netherlands ranges from 48.1 to 58.8%, as determined using two different methods.

Self-referrals in the emergency department: reasons why patients attend the emergency department without consulting a general practitioner first-a questionnaire study.

BACKGROUND: To influence self-referral, it is crucial to know a patient's motives to directly visit the emergency department (ED). The goal of this study is to examine motives for self-referral to the ED and compare these motives in relation to appropriateness. METHODS: All self-referred patients visiting the ED of a Dutch hospital over four separate months in a 1-year period were included. Patients were handed questionnaires that included questions on their reasons to visit the ED directly and where they would seek medical help next time. Additionally, the motives of patients that either appropriately or inappropriately visited the ED were compared. In a previous study on the same patient cohort, the appropriateness of the ED visits was determined using predefined criteria. RESULTS: A total of 3196 self-referred patients were included, and 48.9 % completed the questionnaires. The majority of patients (28.0 %) attended the ED without a referral because they thought they would get help faster; the next reason was the easier access to radiologic and laboratory investigations (answered by 23.8 %); and the third was the symptoms were considered too severe to visit a general practitioner (GP) (answered by 22.7 %). The majority (78.5 %) would attend the ED the next time they are faced with similar symptoms. Appropriate visits were significantly more seen in females, elderly, and patients in higher triage categories. Patients who expect investigations are necessary, think their symptoms are too severe to visit a GP, or would return to the ED next time were more often appropriately visiting the ED. CONCLUSIONS: The choice of patients to self-refer to an ED is often an explicate decision. Patients are looking for specialist help and want fast and easy access to radiologic and laboratory investigations. Even though the primary care network is well developed in the Netherlands, the reasons for self-referral are similar to the reasons found in previous literature based in other countries. Patients who visit the ED because of health concerns visit the ED more often appropriately than patients visiting for practical reasons.

The association between time to antibiotics and relevant clinical outcomes in emergency department patients with various stages of sepsis: a prospective multi-center study.

INTRODUCTION: In early sepsis stages, optimal treatment could contribute to prevention of progression to severe sepsis. Therefore, we investigated if there was an association between time to antibiotics and relevant clinical outcomes in hospitalized emergency department (ED) patients with mild to severe sepsis stages. METHODS: This is a prospective multicenter study in three Dutch EDs. Patients were stratified into three categories of illness severity, as assessed by the predisposition, infection, response, and organ failure (PIRO) score: PIRO score 1 to 7, 8 to 14 and >14 points, reflected low, intermediate, and high illness severity, respectively. Consecutive hospitalized ED patients with a suspected infection who were treated with intravenous antibiotics were eligible to participate in the study. The primary outcome measure was the number of surviving days outside the hospital at day 28 which was used as an inverse measure of hospital length of stay (LOS). The secondary outcome measure was 28-day mortality, taking into account the time to mortality. Multivariable Cox regression analysis was used to estimate the association between time to antibiotics and the primary and secondary outcome measures corrected for confounders, including appropriateness of antibiotics and initial ED resuscitation, in three categories of illness severity. RESULTS: Of the 1,168 included patients, 112 died (10%), while 85% and 95% received antibiotics within three and six hours, respectively. No association between time to antibiotics and surviving days outside the hospital or mortality was found. Only in PIRO group 1 to 7 was delayed administration of antibiotics (>3 hours) associated with an increase in surviving days outside the hospital at day 28 (hazard ratio: 1.46, 95% confidence interval: 1.05 to 2.02 after correction for potential confounders). CONCLUSIONS: In ED patients with mild to severe sepsis who received antibiotics within six hours after ED presentation, a reduction in time to antibiotics was not found to be associated with an improvement in relevant clinical outcomes.

[A man with a painful leg]. / Een man met pijn in het been.

A 72-year-old man with a history of prostate cancer was seen with pain in the right leg and the left arm. He suffered from a clostridial myonecrosis. Physical examination showed typical findings of purple discoloration of the skin and hemorrhagic bullae. The patient eventually died because of septic shock.